Form - 3 In Duplicate EMPLOYEES STATE INSURANCE CORPORATION Return of Declaration Form (Regulation 14) Name and address of the

Factory or Establishments Employer's Code Number I send herewith the Declaration forms in respect of the employees mentioned below. I hereby declare that every person employed as an employee, within the meaning of section 2 (9) of the Employees state Insurance Act 1948 on _____________ in this factory or establishment and in receipt of a remuneration not execeeding Rs. 10,000/- ( excluding remuneration for overtime work ) per month has been included in this list (excepting only those in respect of whom declaration forms have been sent to the Corporation in the past. ) Place Date Serial No ___________ ____________ Distinguishing No with the employer, if any Signature _________________________________________________ Designation _________________________________________ Insurance No. alloted by the corporation (to be entered at the Regional Office)

Name of the employee

Father's or Husband's Name

Continuation Sheet

Signature ______________________

FORM - 5 * Due Date for Submission 12th May / 11th November * Name of Branch Office . Employer's Code No. .

Return of Contributions EMPLOYEE'S STATE INSURANCE CORPORATION (Regulation - 26) Name and Address of the factory or establishment :... ... Particular of the Principal Employer (s) (a) Name... ... (b) Designation ... ( c ) Residential Address ... Contribution period from to. I furnish below the details of the employer's and employee's share of contributions in respect of the undermentioned insured persons. I hereby declare that the return includes each and every employee, employed directly or through an immediate employer or in connection with the work of the factory/establishment or any work connected with the administration of the factory/ establishment or purchase of raw materials, sale or distribution of finished products etc. to whom the ESI Act, 1948 applies, in the contribution period to which this return relates and that the contributions in respect of employer's and employee's share have been correctly paid in accordance with the provisions of the Act and Regulations. Employee's Share Employer's Share . Total Contribution . Details of Challans :Sl. Month Date of Challan No. 1 2 3 4 5 6

Amount

Name of the Bank and Branch

Total amount paid : Rs . Place . Date .. Signature and Designation of the Employer (With Rubber Stamp)

Important instructions : Information to be given in "Remarks Column (No. 9)".

(i) If any I. P. is appointed for the first time and/or leaves during the contribution period indicate "A ..(date) and /or "L(date)* (ii) Please indicate Insurance No. in ascending order. (iii) Figures in Columns 4, 5 and 6 shall be in respect of wage periods ended during the contribution period. (iv) Invariably strike total of columns 4, 5 and 6 of the Return. (v) No overwriting shall be made. Any corrections, if made, should be signed by the employer. (vi) Every Page of this should bear full signature and rubber stamp of the employer. (vii) Daily wages in column 7 of the return shall be calculated by dividing figures in column 5 by figures in column 4 to two decimal places. For * CP ending 31st March, due date is 12th May For CP ending 30th September, due date is 11th November

EMPLOYEES' STATE INSURANCE CORPORATION Employer's Name and Address Employer's Code No. Period from ..to.

Total No. of amount Employee's Average Whether days for Sl. Insurance Name of Insured of Contribution Daily still which Remarks No. Number Person wages deducted Wages continuous wages paid (Rs.) (Rs.) working paid (Rs.) 1 2 3 4 5 6 7 8 9

Total * Date of appointment and leaving the job may be given in remarks column

Signature of the Employer (FOR OFFICIAL USE) 1. Entitlement position marked. 2. Total of Col. 5 of Return checked and found correct/correct amount is indicated. 3. Checked the amount of Employer's/ Employee's contribution paid which is in order/ observation memo enclosed. Countersignature .. U.D.C Head Clerk Branch Officer

FORM - 12 Accident Report from Employer EMPLOYEES' STATE INSURANCE CORPORATION (Regulation 68) 1. Name and Address of Factory / Establishment and Telephone No. 2. Name of Industry or business 3. Employer's Code No. 4. Branch Office 5. Name and address of injured person 6. Sex and Age 7. Occupation 8. Insurance No. 9. Department 11. Hour at which he started work on 10. Shift/Hrs. of work on the date of accident the day of accident 12. Date of hour of accident 13. Exact place of accident 14. Nature and extend of injury (e.g. fatal, 15. Location of injury (right leg, left loss of finger, fracture of leg, scald etc.) hand or left eye etc.) 16. Address of premises where accident 17. Date of death in case the injured happened person dies 18. In case of the accident happened while meeting an emergency, please state :(ii) Whether the injured person, at the time of the accident was employed for the purpose of his (i) Its nature :employer's trade or business in or about the premises at which the accident took place :19. Dispensary / IMP allotted to 20. Dr or Dispensary or Hospital from where injured injured person person received or is receiving treatment 21. Name and Address of witness :1 2 Note :- Accident Report is required to be submitted to the appropriate Branch Office as well as to Insurance Medical Officer / I. M. P. within 24 hours of the receipt of notice of injury. In case of fatal or serious accidents, it must be submitted immediately to avoid legal penal action under section 85. Yes No 22. Whether wages in full or part are payable to him for the days of accident. 23. Whether the injured person was an employee under section 2(9) of the Act on the day of accident. 24. Whether contribution was payable by him for the day on which accident occurred. 25. Cause of accident :(a) State exactly what the injured person was doing at the time of accident i.e. brief description of how the accident occurred (b) Was the injured person, at the time of accident, acting in contravention of Yes No (1) the provision of any law applicable to him . or (2) any orders given by or on behalf of his employer . or (3) Acting without instructions from his employer. . ( c ) In case reply to b(1), (2) or (3) is yes, state whether the act was done for the purpose of and in connection with the employer's trade or business 26. In case the accident happened while travelling in the employer's transport, state whether the injured person was travelling :(1) as a passenger to or from his place of work (2) with the express or implied permission of his employer

(3) the transport is being operated by or on behalf of the employer or some other person by whom it is provided in pursuance of arrangement made with the employer, and (4) the vehicle was being/not being operated in the ordinary course of public transport service I certify that to the best of my knowledge and belief, the above particulars are correct in every respect. Date of despatch of report Signature of the Employer Name in block letters . Designation